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Left occipital hemorrhagic developmental venous anomaly

This male patient presented with sudden onset of severe headaches.
The initial CT scan revealed an intraventricular hemorrhage. Subsequent conventional catheter based cerebral angiography demonstrated a vascular lesion in conjunction with the left posterior cerebral artery, which was felt to be consistent with an arteriovenous malformation, however the possibility of a DVA was also raised. A combined MRI-MRA study was performed for further evaluation.

(Left occipital developmental venous anomaly 1.5 T)
Fig.1 Transverse non-enhanced (above) and contrast-enhanced (below) brain CT images. The non-enhanced images show signs of intraventricular hemorrhage. After intravenous contrast injection enhancement appears in the right trigonal region, suggesting a small paraventricular (choroidal?) arteriovenous malformation.
Fig.2 DSA images after selective injection of the right internal carotid artery (above) and vertebral artery (below). An abnormal vascular blush (arrows) is seen above the calcarine branch of the right posterior cerebral artery on both the lateral (above right) and the oblique (above left) images. No clear evidence is demonstrated however for early venous drainage. In the late phase of the vertebral artery angiography a large venous structure (arrow) is faintly visualized in the proximity of the vein of Galen. This image raises the possibility of a DVA.
Fig.3 Transverse targeted MIP reconstruction from a Gadolinium-enhanced 3D TOF MRA (with 512 matrix and MOTSA) acquisition data set. The calcarine branch of the right posterior cerebral artery appears to have increased flow compared to the left, but is clearly passing by the adjacent vascular anomaly without sending arterial feeders to it.
Fig.4 Sagittal (above) and coronal (below) targeted MIP reconstructions from the Gadolinium-enhanced 3D TOF MRA acquisition data set. The sagittal image shows the vascular anomaly above the calcarine branch of the right posterior cerebral artery. The caput medusae aspect of the DVA is evident on the coronal image.

 

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Fig. 1

Left occipital hemorrhagic developmental venous anomaly, Fig. 1
Left occipital hemorrhagic developmental venous anomaly, Fig. 2
Left occipital hemorrhagic developmental venous anomaly, Fig. 3
Left occipital hemorrhagic developmental venous anomaly, Fig. 4